the bone. This incision extends from the temporal region, above the articulation of the jaw, backward to the point of the mastoid. After ligation of several vessels, the periosteum throughout the incision is carefully pushed toward the auditory canal. By this means the bony edge of the external auditory meatus is exposed for three-quarters of its extent, and at the same time the cutaneous lining of the auditory canal is seen, projecting like a funnel from the bony canal. This cutaneous funnel is loosened from its attachment with a blunt scraper. Care must be taken not to loosen this cutaneous canal too far inward, as the thin lining of the inner canal may tear. This cylinder is now cut through near the drum-head, excepting on the anterior wall. By this means as much as possible of the lining of the auditory canal is left in conjunction with the auricle, and the periosteum is protected as much as possible. If now the auricle be drawn forward, the two edges of the cut in the posterior wall of the cutaneous canal gape apart, and the lumen of the canal and the anterior wall become visible. Now the anterior wall is cut loose from its attachment, and the entire outer end of the cutaneous canal can be lifted from its bony case. The entire bony auditory canal is now exposed to the surgeon's view. The membrana tympani can be inspected by direct light and without the intervention of the length of the cartilaginous canal. Stacke now removes the hammer and membrana tympani, or their remnants, chisels away the osseous lamella above the membrana flaccida and the osseous part of the external wall of the drum-cavity, thus laying bare the attic, or the malleo-incudo-squamous space. The bony frame of the membrana tympani behind and above is also chiselled away until there is no obstacle detected by the probe between the drum-cavity and the auditory canal, and the incus is removed. The tegmen tympani is then inspected. The stapes. is protected by a metal shield arranged for the purpose. If caries is detected it is energetically but carefully scooped out with a sharp spoon. The auricle and the part of the auditory canal in connection with it are now replaced, a drainage-tube is placed in the auditory canal as far as the drum-cavity, and the entire incision is sutured; syringings are entirely avoided. The wound heals per primam in from three to five days. If suppuration exists in the mastoid process it is possible to detect this easily by laying open the aditus ad antrum, and the use of the probe. If cholesteatomatous masses project from this region a diagnosis of mastoid disease may be made. In such a case the incision in the skin may be carried backward and the antrum laid open at the usual spot, and the entire posterior wall of the auditory canal removed as far as the aditus ad antrum and the drum-cavity. The shield in the aditus protects the facial canal and the semicircular canal. The large cavity is to be packed with iodoform gauze, without syringing. The following advantages are claimed for this method:

1. The operation is done with direct light, without speculum, and unhindered by the curves of the canal.

2. Bleeding interferes very little with the operation, on account of the comparatively wide field of vision.

3. All diseased tissue can be surely removed, which amply repays for the trouble of the preliminary operation.

4. It is impossible to fail in the extraction of the malleus, or for the broken

head of the hammer to remain behind, or for the incus not to be found. The operation is possible in the narrowest canal.

5. The operation is unattended by injury to other parts.

6. If during the operation an indication is seen for opening the mastoid (often found only after waiting for weeks), it can be performed during the same narcosis and from the same incision in the skin.

The indications for the excision of the membrana tympani with the malleus, and in some cases the incus, are, according to Stacke

1. As a means of improving the hearing.

(a) In fixation of the malleus due to the results of previous suppuration or adhesive inflammations, even when the stapes is known beforehand not to be normally movable, as in entire calcification of the membrana tympani, isolated hammer-anvil ankylosis, and adhesion of the membrana tympani to the promontory; and

(b) In incurable occlusion of the Eustachian tube.

It is contra-indicated in sclerosis.

2. As a means of curing chronic suppuration of the attic, regardless of the condition of the hearing.

(a) In demonstrable caries of the malleus or incus.

(b) When the malleus and incus are normal, but when the attic is carious. (c) In cholesteatoma of the tympanic cavity.

[It must not be forgotten that a large cresentic incision behind the auricle as is demanded by Stacke, would be followed by considerable drooping of the auricle after healing had taken place.-REV.]

OPHTHALMOLOGY.

UNDER THE CHARGE OF

GEORGE A. BERRY, M.B., F.R.C.S. ED.,

OPHTHALMIC SURGEON, EDINBURGH ROYAL INFIRMARY;

AND

EDWARD JACKSON, A.M., M.D.,

PROFESSOR OF DISEASES OF THE EYE IN THE PHILADELPHIA POLYCLINIC; SURGEON TO WILLS EYE HOSPITAL, ETC.

UVEAL IRITIS.

DR. GRANDOLEMENT, under the caption "Uveite Irienne," urges (Recueil d'Ophthalmologie, Ann. xiii. No. 5) the recognition of this especial form of inflammation of the iris as distinct from inflammations which affect the anterior portion or true iris stroma, comparing its relation to the latter with that of pleurisy to pneumonia. Cases of inflammation of the uvea of the iris do not present the violent symptoms of iritis, such as increased lachrymation photophobia, the pericorneal zone of hyperæmia, discoloration of the iris, or obstruction of the pupil. They occur insidiously, with a little impairment

of vision, points of obscuration, or musca volitantes, without noticeable redness or pain of the eye, the patient, perhaps with difficulty, remembering that there had been a little redness or pain for two or three days. After some weeks the symptoms disappear, to reappear months later in the same or in the other eye. This occurs repeatedly, until the physician when consulted is surprised to discover the evidences of numerous synechia without any history of iritis. There may also be loss of transparency in the vitreous, sometimes even shreds of opacity and consequent indistinctness of the fundus.

This affection differs also from true iritis as to its causes; syphilis, rheumatism, etc., are commonly absent. It especially affects women between the ages of thirty and fifty, of regular lives, mothers of families, but compelled by poverty to hard daily labor. The treatment for true iritis is also quite ineffective, mydriatics, mercury, salicylates, etc., being powerless to loosen adhesions already existing, or to prevent the formation of new ones. The remedies recommended are the excision of the adhesions by a large iridectomy, or the detaching of the adhesions by one of the operations for that purpose. The iridectomy has given the most satisfactory results.

THE CORRECTING GLASSES IN APHAKIA.

DR. F. DIMMER, after a full discussion (Klinische Monatsbl, für Augenheilk., Jahrg. xxix. p. 111) of the optical factors involved, concludes that when the refraction has been tested in aphakia with the ordinary biconvex lenses, if the lens that appears to give the best vision be ordered in the usual manner, and supplied by the optician in connection with the cylindrical lens required in the ordinary way with the spherical curve all on one surface of the lens, the lens so furnished will be too strong. In ordering after such a test it is necessary to reduce the strength of the spherical quite notably to obtain the desired combination. To avoid this, the plano-convex spherical lenses should be used in the testing, and the spherical curve turned from the eye as it will be in the finished glass. The cylindrical lenses commonly furnished in the trial sets are already made plano, and they should be used with the curved surface in the same position as will be occupied by the cylindrical surface of the combination to be ordered.

CONGENITAL PTOSIS AND ASSOCIATED MOVEMENT OF THE

PARALYZED LID.

DR. THEODOR PROSKAUER reports, in the Centralbl. für prakt. Augenheilk., Jahrg. xv. p. 97, one of these interesting cases. The patient applied on account of recent rheumatic paralysis of the right facial nerve, and presented also congenital ptosis on the left side with paresis of the left superior rectus muscle; the eyeball could be turned but little upward. Ordinarily the opening between the left upper and lower lids was but two or three millimetres, but by an effort and with the aid of the muscles of the brow this could be increased to six millimetres. As soon, however, as the mouth was opened the lid was raised without any aid from the accessory elevators, and without any spasmodic action. The maximum separation of the lids was ten millimetres, exposing the whole upper portion of the cornea. But this was not

long maintained, the lid drooping before the mouth was closed. The pupils were equal, and the ophthalmoscope showed a small choroidal crescent; fundus otherwise normal; hyperopic astigmatism. Vision only one-fourth.

CRUDE PETROLEUM IN THE TREATMENT OF CONJUNCTIVITIS.

DR. A. TROUSSEAU (Recueil d'Ophthalmologie, Ann. xiii. No. 5) finds among many substances experimented with, with the idea of finding a substitute for silver nitrate and copper sulphate in the treatment of conjunctivitis, the crude petroleum of the Caucasus alone worthy of especial mention. It is not irritant, is tolerated by the ulcerated cornea without pain, and provokes no complaint or resistance to its application on the part of the patient. Its therapeutic action is superior to that of its derivatives. It was tried in catarrhal, muco-purulent, follicular, granular, vernal, and phlyctenular conjunctivitis, and the conclusions reached from this clinical experience and certain laboratory tests of its antiseptic properties are: It is an antiseptic agent favorably influencing conjunctival affections, always well borne, never causing a painful reaction, and is easily applied. It is indicated for children and others that dread the more painful local applications, and is capable of affecting a cure alone in some cases, and in others of hastening or completing a cure when preceded or followed by other remedies, or associated with other recognized antiseptics.

DISEASES OF THE LARYNX AND CONTIGUOUS STRUCTURES.

UNDER THE CHARGE OF

J. SOLIS-COHEN, M.D.,

OF PHILADELPHIA.

ENVELOPMENT OF THE UVULA IN THE PALATINE FOLDS.

In the Revue de Laryngologie, No. 20, 1891, the compiler reports an instance of total envelopment of the uvula in a membrane extending from one tonsil to the other, and in continuity with the anterior palatine folds. The gentleman in whom this occurred had always suffered with an irritable throat, which annoyed him most whenever he was under the hands of the barber. The uvula was quite large and was readily disengaged by bilateral excision of V-shaped sections of the membrane with serrated scissors. The topical irritation and the cough were permanently relieved.

By one of those curious laws of similars, so often noted in all vocations, a second instance of the same kind was brought to the compiler's notice before the publication of the record noted above. This was in a female, now studying medicine in Philadelphia. These two are the only instances that have been recognized in a long practice largely confined to lesions of the throat. VOL. 103, No. 1.-JANUARY, 1892.

7

TUBERCULOUS UVULITIS.

DR. RAGONEAU reports (Revue de Laryngologie, No. 20, 1891) an instance of bilobar hypertrophy of the uvula, with a tubercle in the centre of each lobe surrounded with miliary granulations. Dysphagia was extreme. The lesion appeared some time after the cure of a tuberculosis of the larynx, which had occurred in the fourth year of a pulmonary tuberculosis.

A CASE OF PUSTULES OF THE THROAT, PHARYNX, NOSE, AND LARYNX. Dr. AuduberT, of Luchon, reports (Rev. de Lar., etc., No. 8, 1891) the case of a cachetic woman, fifty-two years of age, much depressed in health in consequence of a protracted series of misfortunes, who was under observation in Moure's clinic for several months with successive pustular eruptions in the sublingual mucous membrane, both sides of the septum narium, the anterior palatine fold, the vocal band and the adjacent internal face of the arytenoid, and in the vault of the palate. The stage of ulceration only was noted in these regions, except when the arch of the palate was involved, at which time a veritable phlyctena was seen, which, when pierced, gave exit to a small quantity of pus, and subsequently when a vesicle was seen on the palate. During the process isolated echthyma was manifested on the dorsal face of one of the thumbs, and isolated pustules appeared on one of the nipples, and on the anterior region of the neck. Treatment seemed to be of little avail, but cicatrization slowly ensued. There was no fever, but little topical pain, simply a sensation of discomfort and dryness of the throat, and not even any alteration in the voice when the larynx was invaded. It seems to the recorder that the case indicates an infectious process manifested by pustules in the skin and mucous membrane of short duration, and presents a confirmation of the opinion advanced by some observers that cutaneous affections may present upon the mucous membrane with their ordinary symptoms.

RETROPHARYNGEAL ABSCESS.

Two instances in adult males, in which the trachea had become pushed to one side, are reported by GEORGE FOY (The Medical Press, No. 2736, 1891). Both occurred in subjects living under wretched hygienic condition. In one the disease was attributed to abscess at the root of a carious tooth in the lower jaw. Both were relieved by external incision, which gave issue to pus in large quantities. References to similar cases are given.

DISEASE OF THE MEDIAN RECESS OF THE PHARYNX.

In an excellent article (Wiener klin. Woch., No. 40, 1891) on the diseases of the so-called bursa pharyngea, PROF. O. CHIARI reviews the cases published by Tornwaldt and many others, and he records eight of his own, all he has seen in some 3000 patients with disease of the throat or nose. His conclusions from this study do not lead him to regard, as others have done, pharyngitis sicca as a result of disease of the structures under consideration; nor to find that the associated diseases of the nose and pharynx, so usually